| Your Age |
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| Your gender |
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| Transport |
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| How were you referred? |
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| How did you find the organisation of your appointment? |
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| Did you receive information regarding the location of the clinic and the time to attend? |
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| At which location were you seen? |
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| How satisfied are you with your consultation with the Health Professional? |
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| Please comment |
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| Do you feel that this service has helped the management of your condition? |
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| Please comment: |
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| Any suggestions? |
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